Cardiac Biomarkers and Multimodality Imaging in Surveillance During Oncologic Therapy: An Integrated Approach to Cardio-Oncology

Modern oncologic therapy has dramatically improved cancer survival, yet many of the agents responsible for these gains-anthracyclines, human epidermal growth factor receptor 2-targeted therapies, vascular endothelial growth factor inhibitors, immune checkpoint inhibitors, and chest radiotherapy-carry meaningful cardiovascular risk. The emerging discipline of cardio-oncology has transformed the clinical approach to this challenge, and the 2022 European Society of Cardiology guidelines on cardio-oncology have provided the first comprehensive framework for cancer therapy-related cardiovascular toxicity, including its early detection through cardiac biomarkers and advanced imaging. Cardiac troponin (preferably high sensitivity) and natriuretic peptides (B-type natriuretic peptide or N-terminal pro B-type natriuretic peptide) serve as reliable, accessible markers of cardiomyocyte injury and hemodynamic stress, respectively, and are now formally embedded in surveillance algorithms across all major society documents. Growth differentiation factor 15, a stress-responsive cytokine, has emerged as a particularly promising next-generation biomarker, with recent data demonstrating predictive value for cardiotoxicity in human epidermal growth factor receptor 2-targeted breast cancer therapy. On the imaging side, global longitudinal strain by speckle-tracking echocardiography enables sensitive detection of subclinical left ventricular dysfunction long before left ventricular ejection fraction declines, and the SUCCOUR and SUCCOUR-MRI trials have provided important randomized data on strain-guided cardioprotection.